Bacterial infection in the fetus and newborn

The Role of C-reactive Protein Estimation in Determining the Duration of Antibiotic Therapy in Neonatal Sepsis

INTRODUCTION

Septicemia is globally considered the most important cause of neonatal morbidity and fatality. Serum C-Reactive Protein (CRP) is an acute phase reactant, which is brought out in response to the inflammatory reaction. It is prophesied to drop down speedily after the coherent weeding out of microbial incitation due to the short half-life of CRP. CRP levels reflect the individual's association between microbial infection and defensive mechanisms.  Methods: This hospital-based cross-sectional study included 150 admitted patients with suspected sepsis in the Department of Pediatrics, Rajendra Institute Medical Sciences (RIMS), Ranchi, India, over a study period of one year (2020 to 2021). CRP was estimated on the day of admission and repeated after 72 hours, on the fifth day, and on the seventh day for serial values of CRP, and the findings were compared by making three groups. Further, the research participants were designated to three different groups according to the CRP estimation levels.

RESULTS

Out of the 150 assumed neonatal septicemia patients, antibiotics were paused in 42 neonates (28%) within 72 hours. In group 2, 8% of neonates' antibiotics were stopped in five days, and a total of 102 neonates (68%) could be discharged on the seventh day of antibiotic therapy as their CRPs became negative on the third day and seventh day consecutively, along with negative blood culture reports. In group 3, antibiotics of 48 neonates (32%) were continued beyond seven days.

CONCLUSION

CRP has a skyscraping specificity and negative predictive values (NPV); thus, by estimating serial CRPs, the antibiotic therapy duration can be determined, which further helps determine the period of hospitalization.

The primary microbial pathogens associated with premature rupture of the membranes in China: a systematic review

To describe the spectrum of pathogens isolated from Chinese women experiencing premature rupture of the membranes (PROM) and those of their neonates, in order to provide effective management of PROM. We searched Ovid Medline, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and VIP Database for Chinese Technical Periodicals up to April 2012. The quality of studies was assessed utilizing the Strengthening the Reporting of Observational Studies in Epidemiology Statement. Among the included 36 studies, 11 (30.55%) were deemed to be at Level A, 12 (33.33%) at Level B, three (8.33%) at Level C, and 10 (27.78%) at Level D. Staphylococcus and Escherichia coli were the two primary microorganisms isolated from women with PROM and their infants. Subgroup analysis showed the distribution of microorganisms from the six regions of China varied. Staphylococcus bacteria were resistant to penicillins, except oxacillin, but more sensitive to first- and second-generation cephalosporins. Escherichia were sensitive to first- and second-generation cephalosporins and were more sensitive to aztreonam than cephalosporins. The main pathogens derived from women with PROM and their newborns were Staphylococcus and E. coli, which differs from the pathogens in Western countries. Hence, one might infer that the pathogens involved in PROM should be defined in each region to maximize antibiotic effectiveness. In addition, randomized controlled studies are needed to compare prophylactic use of antibiotics versus use of antibiotics after a positive culture for newborn infants with a history of PROM.

The effects of preservation procedures on antibacterial property of amniotic membrane

Amniotic membrane (AM), the innermost layer of the fetal membranes, has been widely employed in the surgical reconstruction and tissue engineering. Expression of the antimicrobial peptides such as defensins, elafin and SLPI which are essential elements of the innate immune system results in antibacterial properties of the AM. Preservation is necessary to reach a ready-to-use source of the AM. However, these methods might change the properties of the AM. The aim of this study was to evaluate antibacterial properties of the AM after preservation. Antibacterial property of the fresh AM was compared with cryopreserved and freeze-dried AM by modified disk diffusion method. Staphylococcus aureus ATCC 25923, Pseudomonas aeruginosa ATCC 27853, Escherichia coli ATCC 25922 and two clinical isolated strains of E. coli were cultured in Mueller Hinton agar and a piece of the AM was placed on agar surface. After 24h incubation, the inhibition zone was measured. In addition, one of the most important antibacterial peptides, elafin, was measured by ELISA assay before and after preservations procedures. Antibacterial properties of the AM were maintained after cryopreservation and freeze-drying. However, the inhibition zone was depending on the bacterial strains. The cryopreservation and freeze-drying procedures significantly decreased elafin which shows that antibacterial property is not limited to the effects of amniotic cells and the other components such as extracellular matrix may contribute in antibacterial effects. The promising results of this study show that the preserved AM is a proper substitute of the fresh AM to be employed in clinical situations.

Bacterial colonisation and infection in lesions of the central nervous system

A study was made of the pattern of bacterial colonisation during the first month of life in a group of 116 newborn infants with spina bifida. 55 patients subsequently developed a total of 90 infective episodes and in over three-quarters of these episodes there was a correlation between the infecting and colonising organisms. The principal sites of infection were the lesion, the ventricles and the urinary tract, and infection accounted for 27 of the 35 deaths in the series. Some of the factors governing the pattern of colonisation and the development of infection in newborn patients are discussed.

Neonatal meningitis in Harare, Zimbabwe: a 2-year review

A 2-year review of neonatal meningitis was undertaken at a referral hospital in Zimbabwe to determine the pattern of bacterial isolates from the cerebrospinal fluid, the clinical presentation and the immediate outcome. During the study period, 94 cases were identified and the overall mortality was 41%. Group B Streptococcus was the predominant organism isolated (61%) and was associated with 42% mortality. Low-birthweight babies and babies with Gram-negative meningitis had mortality rates of 71 and 62%, respectively.

Meningites purulentas em crianças no primeiro ano de vida

Foram estudadas 169 crianças com diagnóstico de meningencefalite purulenta aguda e que manifestaram a doença no primeiro ano de vida. São feitas considerações sobre os achados clínicos e neurológicos, em subgrupos etários. É ressaltada a maior freqüência da doença entre lactentes até 6 meses de idade.

Perinatal listeriosis; more common than reported (2 case reports and revision of literature)

Listeriosis is again reported with an increasing frequency in recent literature. It is reported to be the third cause of neonatal sepsis [4,7]. Hereby we are presenting two cases of perinatal listeriosis together with a summary of literature.

The prevalence of bacteriuria among high risk neonates in Nigeria

Among the 446 high risk neonates studied for significant bacteriuria and pyuria in the neonatal wards of the Obafemi Awolowo University teaching hospital Complex, Ile-Ife, 7.6% and 5.8% were positive for significant bacteriuria and pyuria respectively, while none of the 81 infants in the control group were positive. Males and females were similarly affected and there was no seasonal variation in the prevalence of pyuria or bacteriuria. It is noteworthy that 25 (96%) of the 26 pyuria neonates also had bacteriuria emphazising the significance of pyuria as a possible screening method for urinary tract infections in neonates. The clinical problems in the neonates studied included prematurity, low birthweight, neonatal jaundice, fever, CNS symptoms, ophthalmia neonatorum, prolonged rupture of the membranes (PROM), respiratory distress, septic cord/skin, diarrhoea, vomiting and feeding problems. Only prematurity and low birthweight were significantly associated with bacteriuria in the neonates studied. The organisms encountered in this study were Escherichia coli (58.4%), Klebsiella species (35.3%) and Proteus species (5.9%). Of the bacterial isolates, 67% were sensitive to Ampicillin and 97% to Gentamycin. The combination of these antibiotics was effective in all cases in the present study. The study has highlighted the need for routine urine culture in our high risk neonates.

Neonatal bacteraemia in Wesley Guild Hospital, Ilesha, Nigeria

In a study on neonatal bacteraemia among the high-risk neonates admitted into our neonatal unit at Wesley Guild Hospital, Ilesha, the incidence of bacteraemia in babies born in the hospital was 17/1000 live births and 71.6/1000 total admissions into the unit. Gram-negative bacteria accounted for about 58.1% of bacteria isolated and Staphylococcus aureus for 62% of the isolated Gram-positive bacteria. Among the commonly used antibiotics, gentamicin is the most favoured by the sensitivity test. S. aureus appeared more sensitive to erythromycin than to cloxacillin or ampicillin. The present policy of using the combination of gentamicin and cloxacillin and/or ampicillin is adequate for most agents encountered and therefore should continue. It is suggested that proper antenatal care, adequate supervision of delivery, better neonatal care and provision of better laboratory facilities will help to reduce the incidence of neonatal bacterial infection, improve the management of neonatal infection and reduce the morbidity and mortality from bacterial infection.

Purulent meningitis in the newborn

Neonatal meningitis is characterized by unusual clinical manifestations caused by unusual organisms (with a marked predominance of gram-negative organisms), a poor prognosis due to the failure of antibiotics to penetrate the blood-brain barrier, and frequent complications (ventriculitis, hydrocephalus, and brain damage). The literature is reviewed and our personal experience described. The clinical and bacteriological findings, the complications and results of various therapeutic regimes, and the factors affecting prognosis are discussed.

Randomised controlled trial of effect of raw and holder pasteurised human milk and of formula supplements on incidence of neonatal infection

Supplementary formula feeds inhibited the protective effect of expressed raw and pasteurised human milk in 226 high-risk neonates in a randomised controlled trial. The infection rate in the group given pasteurised human milk and formula (33%) was significantly higher than the rates in the groups given raw human milk (10.5%), pasteurised human milk (14.3%), and raw human milk and formula (16%). This accords with the impressions that some of the association of infection with artificial feeding is partly attributable to the lack of the protective effect of human milk. Heating expressed human milk to 62.5 degrees C for 30 min significantly reduces its protective effect.

Sepsis and hypothermia in the newborn infant: value of gastric aspirate examination

Bacteriologic examination of blood, urine, CSF, and gastric aspirate was performed in 88 babies admitted with hypothermia (rectal temperature less than 35 degrees C) during the neonatal period. Infection was common in infants older than 3 days (late-onset hypothermia). In 36 of the 44 (81.8%) infected babies, the gastric aspirate was abnormal, whereas it was abnormal in only three of the 23 (13%) not infected. Infection was much less common in babies younger than 3 days (early-onset hypothermia), and in these the gastric aspirate was mostly normal. Two babies had RDS-like symptoms, and streptococci were cultured from the gastric aspirate. Examination of the gastric aspirate is a quick, efficient method of diagnosing severe infection, not only immediately after birth but throughout the neonatal period.

Efficacy of chloramphenicol in the treatment of neonatal and infantile meningitis: a study of 70 cases

The efficacy of chloramphenicol in the treatment of 21 neonates and 9 infants with proven meningitis and 37 neonates and 3 infants with suspected meningitis was evaluated from mortality and morbidity data, and by assay of the drug in serum and cerebrospinal fluid. Minimum inhibitory concentrations (MICs) were established for ten isolates. 25% of neonates and 50% of infants had subtherapeutic concentrations of chloramphenicol in serum or cerebrospinal fluid. Dosage was less than that currently recommended in over half of these subjects. Mild toxicity (reversible thrombocytopenia) was observed in only 1 of 20 babies being treated at the recommended dose. Toxic reactions, including the grey-baby syndrome, occurred in 10 babies receiving higher doses. In 4 cases, doses up to ten times that prescribed had been given, and death of 1 baby was attributable in part to chloramphenicol toxicity. 5 of 21 neonates and 1 of 9 infants with bacteriologically proven meningitis died, an overall mortality of 20%. Those infected with gram-negative bacteria had a higher mortality than those infected with gram-positive bacteria (p less than 0 . 05). 21% of the survivors had neurological sequelae. Therapeutic concentrations of chloramphenicol will be achieved in serum and cerebrospinal fluid with daily doses of 25 mg/kg in preterm and term infants during the first week of life and 37 . 5-50 mg/kg for older term babies. The drug should be assayed at 48-hour intervals, to maintain concentrations in the therapeutic, non-toxic range. Dosage should be increased when the peak serum concentration falls below 20 mg/l and decreased when the trough serum concentration exceeds 15 mg/l or the peak concentration exceeds 30 mg/l.

A planned prospective evaluation of the anti-infective property of varying quantities of expressed human milk

This paper comprises 261 low birth weight infants who were divided into four groups with different feeding schedules. Group I--expressed human milk for all the feeds; Group II--human milk for half the feeds and the nursery formula for the rest; Group III--colostrum, 20 ml three times a day along with the nursery formula; and Group IV--control--only the nursery formula. The groups were matched by means of a randomized block design for identifiable factors which could predispose to the occurrence of infection. Infections were found to be significantly less in the groups which received human milk (p less than 0.001).

Epidemiological study of klebsiella infection in the special care baby unit of a London hospital

Of the babies admitted to the Special Care Baby Unit of the Royal Free Hospital over 20 months, 10.2% were infected or colonised by klebsiella. The fluorescent antibody technique was used to identify epidemics caused by three strains: capsular type 8 K. aerogenes, type 68 K. oxytoca, or type 13 K. aerogenes, each of which was predominant at a different time, exhibited a difference in virulence, and showed a predilection for different sites of infection. Intestinal colonisation was frequently followed by the presence of sepsis in other sites by the same capsular type. Antibiotic administration led to a higher incidence of klebsiella infection, while the widespread use of compounds containing hexachlorophane could have contributed to skin colonisation and infection by klebsiella. An environmental survey indicated that 1% Hycolin failed to disinfect the incubators, that the babies were the reservoirs of the organisms, and that transmission was due to inadequate hand-washing of nurses and mothers. The mothers were found to have been uninformed of hygienic techniques. They were observed in various practices which could have contributed to the spread of the organism, including contaminating communal areas and handling babies other than their own. It has been recommended that the mothers of premature infants be instructed in the hygienic measures required in dealing with this susceptible population and that the nursing and medical staff be more strict in their own observance of these procedures.

Umbilical artery catheterization in newborns. II. Infections in relation to catheterization

Infections, as a complication of umbilical artery catheterization, were studied in 65 sick newborn infants. Every second day during the catheterization period peripheral blood cultures as well as blood samples for white cell count and platelets were taken. Cultures were taken from the catheter tips and from the umbilicus at the time of withdrawal of the catheter. Local or systemic antibiotics were not used prophylactically, but on rather broad clinical indications. No case of septicemia was found, but 8 infants had positive blood cultures and 16 had positive catheter tip cultures. Positive catheter tip culture occurred more often in infants who were born before 32 weeks of gestational age. Neither the duration of the catheterization nor the treatment with antibiotics influenced significantly the frequency of positive cultures.

Neonatal septicemia and perinatal risk factors

Many methods for screening and prediction of neonatal septicemia have been tried. In this study a score, related to both perinatal risk factors and neonatal diseases, was tested upon healthy newborn infants, infants with septicemia and infants with other diseases. Statistical differences were found between infants with neonatal septicemia and infants with other neonatal diseases as well as normal newborns. It was also possible to find a relationship between certain predisposing factors and predominance of certain pathogens. Complications during pregnancy and delivery were most often found in the group B streptococcal, combinations of invasive procedures and neonatal diseases in the staphylococcal group and surgical procedures in the gram-negative group.

Perinatal listeriosis--a review of twelve patients

From July, 1974 to February, 1978, we managed 12 infants with listeriosis. This infection presented in two distinct forms: an early-onset type (nine patients), often representing a congenital infection following maternal illness, and a late-onset type in which the patient presented with meningitis (three patients). Of our nine infants with early-onset disease, three died, three developed permanent sequelae, and only three were normal at follow-up. Appropriate early management in the perinatal period may improve the outlook in this condition. Affected infants were often premature and had pneumonia, rash, and hepatosplenomegaly at birth. Prenatal clues to the diagnosis included maternal fever, abdominal pains, and leukocytosis with meconium staining of the preterm amniotic fluid. Examination of gastric aspirate at birth showed gram-positive coccobacilli. Antibiotic therapy should be started prenatally and continue for three weeks after birth to prevent recurrences of the late-onset type. This late-onset disease presented as meningitis after the second week of life and responded well to antibiotics. Our three patients recovered without sequelae.

Longterm follow-up of neonatal septicemia

The longterm prognosis of neonatal septicemia during the first four weeks of life has been estimated. Of 90 infants with the diagnosis of neonatal septicemia during a five-year period, 1969--1973, 65 infants survived the initial treatment. Another two infants died with complications of their main disease, intestinal atresia, at the age of two months. Thus the total mortality in neonatal septicemia in this series was 30%. The remaining 63 children have been investigated between ages of 2 1/2 and 6 1/2 years. Of these 63 children we have found 14 children (22% of the surviving) with handicaps where the septicemia can be regarded as a possible cause of the handicap. Of these 14 children only six had an "uncomplicated" septicemia while four of them had meningitis and four had osteomyelitis. Furthermore, of the 14 handicapped children nine were delivered preterm (28--36 weeks) and all of them had one or more additional neonatal diagnoses than septicemia. The prognosis, both immediate and longterm, of neonatal septicemia in the present series compares favourably to most international studies. The importance of early detection together with an aggresive treatment of the septicemia is stressed and is considered as the main reason for the good prognosis.

Pharmacokinetic aspects of streptomycin treatment of neonatal septicemia

Patients with suspected neonatal septicemia were treated with ampicillin, cloxacillin, and streptomycin. The plasma concentrations of streptomycin were followed. First, the levels were determined during a full dose interval (12 h) in 11 infants. The results were used for development of a routine system for monitoring the plasma levels in all streptomycin treated newborns. This system, the "3-point check", involved blood sampling at 1, 3, and 5 h after administration during every second dose interval. The results of this routine procedure were evaluated both in a retrospective and prospective study. The "3-point check" gave a sufficient description of the total exposure to streptomycin under routine clinical conditions and continuous information to the physician in charge of the patient about the drug level. In 9 cases of 50, the report from the laboratory resulted in dose change for correction of a too low or too high plasma concentration. The dosage used, 7.5 mg streptomycin intramuscularly every 12th hour, appeared to be satisfactory in most patients. Peak values rarely exceeded 30 microgram/ml and were usually lower than 25 microgram/ml. Almost half of the children had plasma levels below 5 microgram/ml at the end of the dose interval (after 12 h). Although the correlation between pharmacokinetics and clinical outcome is difficult to establish in neonatal sepsis, we suggest that our guiding principle to avoid plasma levels above 25 microliter/ml is reasonable. In 35 out of 78 patients an otological examination of the newborns was performed within 13 months after streptomycin treatment and no signs of hearing defects were noted.

Group B streptococcal infection in neonates

A study of 866 vaginal swabs from non-pregnant women showed that 167 (19.3%) contained Group B beta-haemolytic streptococci, with a predominance of Types 3 (31.4%) and Ib (25.2%). The incidence of severe neonatal infections due to Group B streptococci during a 3 1/2 year period at The Prince of Wales Hospital was examined, and a study was made of the distribution of serotypes and associated clinical features (including prematurity and abnormal deliveries) in 16 neonates with septicaemia and/or meningitis admitted to the Royal Alexandra Hospital for Children, and the Paediatric Department of The Prince of Wales Hospital. From this study it was concluded that prophylactic antibiotic therapy should be administered to neonates with evidence of Group B streptococcal colonization of the throat, umbilicus, or gut, when there is also evidence of prematurity, prolonged interval between membrane rupture and delivery, or other associated obstetric complications.

Prevention of infection in nurseries for the newborn

Prevention of infection in nurseries involves consideration of the design of hospitals, wards and equipment, the study of nursing and domestic procedures, the monitoring of environmental flora and the planning of antiseptic and antibiotic policies. These subjects cannot be considered in isolation from each other and are most suitably managed by a Control of Infection Committee. Ultimately the safety of infants in nurseries rests upon the degree to which each individual involved in their care pays attention to the agreed policies of general and personal hygiene.

Incidence, technique of isolation, and treatment of group B streptococci in obstetric patients

A prospective study was performed to determine the incidence of group B streptococci cultured from the cervix in a series of obstetric clinic patients at St. Margaret's Hospital. Cultures were taken during each trimester and planted to both a blood agar plate and a selective broth medium. Of a total of 812 cultures, 18 were positive, an over-all incidence of 2.2 per cent. During the first, second, and third trimesters, 2.2 per cent, 2.5 per cent, and 1.9 per cent of cultures were positive, respectively. Women with positive cultures were treated with a 10 day course of oral penicillin or a suitable alternative; four of 16 had persistent positive cultures at the end of the first treatment period, three of these four responded to a second course of antibiotics, and the remaining patient responded after a third treatment course. The total number of positive cultures by selective broth was 24, compared to nine in blood agar, indicating a 2.7-fold increase in pickup by the selective broth.

Interaction of E. coli strains with human serum: lack of relationship to K1 antigen

Twenty-eight strains of E. coli isolated from infants were compared with respect to opsonic requirements, sensitivity to serum, and ability to activate serum chemotactic factors. Six of the strains were isolated from stools of healthy newborn infants; 22 were isolated from the cerebrospinal fluid or blood of infants with meningitis and/or septicemia. Eighteen of the strains had K1 polysaccharide antigen. Fourteen of the strains (seven with K1 antigen) activated complement via the alternative pathway and all of these strains were well opsonized in 4% pooled human serum. A higher concentration of serum was necessary to opsonize 12 of the 14 strains that did not activate the alternative pathway. A wide variation was also found in opsonic requirements of E. coli strains isolated from healthy and sick infants. There was no relationship of the K1 antigen to opsonic requirements, to capacity to activate complement via the alternative pathway, to generation of chemotactic factors, or to sensitivity to serum cidal activity. Therefore, the association of E. coli with K1 antigen and neonatal meningitis did not appear to be related to these bacteria-serum interactions.

Nosocomial infections in a newborn intensive-care unit. Results of forty-one months of surveillance

We detected a 24.6 per cent nosocomial infection rate (222 infections in 138 infants) among 904 infants hospitalized for over 48 hours in a regional newborn intensive-care during 41 months of surveillance. Surface infections accounted for 40.1 per cent of the total, pneumonia for 29.3 per cent, bacteremia for 14.0 per cent, surgical-wound infection for 8.1 per cent, urinary-tract infection for 4.5 per cent, and meningitis for 4.0 per cent. Staphylococcus aureus (47.3 per cent) and gram-negative enteric bacilli (45.1 per cent) were the most common organisms recovered. Nosocomial infection rates were significantly higher in infants with a birth weight less than 1500 g (P less than 0.001). The mortality rate in infants with any nosocomial infection was 33 per cent in contrast to 14 per cent in non-infected babies (P less than 0.001). Nosocomial infections are a major problem in newborn intensive-care units.

Effect of gestational age and intrauterine nutrition on plasma transferrin and iron in the newborn

Plasma concentrations of transferrin and iron were measured in the cord blood of babies of varying gestational age and birthweight. Tranferrin and iron concentrations rose with gestational age; values in light-for-dates babies did not differ from those in babies of appropriate weight. In the last trimester of pregnancy plasma transferrin and iron concentrations in the fetus are affected by the maturity of the pregnancy but are independent of the nutritional status of the fetus. The low transferrin levels, particularly in preterm babies, may caution the use of iron especially by the parenteral route in the neonatal period, but we are wary of abandoning on this evidence alone the well tried clinical custom of giving oral iron to preterm babies who are not breast fed.